HospitalInspections.org

Based on interview and record review, the facility failed to document according to policy for 9 (P-1, 2, 3, 4, 6, 7, 8, 9, 10) of 10 records reviewed, resulting in the potential for unrecognized and unmet care needs and increased risk for negative outcomes. Findings include:

See tags:
A-0396 Failure to update care plans
A-0398 Failure to document nursing assessments

Based on interview and record review, the facility failed to maintain and update an individualized care plans for 6 (P-1, P-2, P-3, P-4, P-6, P-8) of 10 records reviewed, resulting in the potential for unmet care needs and negative outcomes for these patients. Findings include:

P-2: This 45-year-old male was admitted to the facility on 2/21/25 with a diagnosis of major depressive disorder. During record review on 3/31/25, it was noted that the patient had an unwitnessed fall and hit his head on 2/23/25 and was transferred to the emergency department for evaluation. The master treatment plan failed to indicate the patient fall on the acute medical problems list.

In addition, the daily nurse progress notes failed to include observations or interventions related to the treatment plan or progress toward meeting the goals for all days except 2/27/25, where the nurse documented "patient is working towards goals."

P-3: This 22-year-old female was admitted to the facility on 2/25/25 with a diagnosis of paranoid schizophrenia. During record review on 3/31/25, it was noted that the daily nurse progress notes failed to include observations or interventions related to the treatment plan or progress toward meeting the goals. It was also noted that the treatment plan failed to include a date where goals were achieved or discontinued.

P-4: This 59-year-old male was admitted to the facility on 1/15/25 with a diagnosis of major depressive disorder. During record review on 3/31/25, it was noted that the patient had fallen in his room, hit his head, and was transferred to the emergency department for evaluation. The master treatment plan failed to indicate the patient fall on the acute medical problems list.

It was also noted that the daily nurse progress notes failed to include observations or interventions related to the treatment plan or progress toward meeting the goals. It was also noted that the treatment plan failed to include a date where goals were achieved or discontinued.

P-6: This 28-year-old female was admitted to the facility on 3/21/25 with a diagnosis of major depressive disorder. A medical consult was conducted on 3/23/25 regarding a fasting blood sugar of 111. The physician ordered an 1800 calorie diet and Metformin 500mg twice daily. During record review on 3/31/25, it was noted that the master treatment plan failed to include diabetes on the acute medical problems list.

These findings were reviewed and acknowledged by the assistant chief nursing officer (Staff-L) during an interview on 3/31/25 at 1215.


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P-1 was admitted to the facility on 2/13/2025 for hallucinations, delusions and agitation. On 2/16/2205 at 1220, P-1 fell while in the cafeteria.

P-1's nursing fall treatment plan was initiated on 2/16/2025. Three short term goals were included on the treatment plan and they included "Patient will report fall related pain/injury immediately to staff," "Patient will participate in review of possible fall causes," and "Patient will demonstrate use of fall prevention measures included in fall precautions." The plan revealed that only the "Patient will report fall related pain/injury immediately to staff" was documented as initiated with a target date of 2/26/25. There was no other documentation or target dates for the other two goals.

P-1's master treatment plan was updated on 2/16/2025 with the word "Fall" and there was no other documentation about the date resolved and no additional updates were documented on subsequent days relating to the fall.

P-8 was admitted on 12/31/2025 for major depression that included seizure disorder. P-8's history and physical revealed that the plan for P-8 was to start P-8 on Keppra 750 mg twice a day.

On 1/2/2025 at 0800, P-8 had a consult for seizure disorder with the plan "Patient will be given Keppra 1500 twice a day." P-8's initial master treatment plan created on 1/3/2025 did not have any documentation about seizure disorder.

On 1/6/2025 at 0800, P-8 had a consult for "Patient states that (they) had a seizure for 10 minutes." The consult note revealed that "per staff nurse, it was not a seizure, Pt sleeping, will reevaluate in am."

On 1/7/2025 at 0900, P-8 had a consult for the seizure disorder and the plan included "Patient will continue with the Keppra. We will consult the neurologist."

According to P-8's master treatment plan, there was no documentation about seizure disorder from 1/3/2025 to 2/4/2025. On 2/5/2025, P-8's master treatment plan revealed "no seizure activity noted."

On 4/1/2025 at 1200, Staff C acknowledged the findings and confirmed the medical treatment plans should be updated as needed in real time. Staff C also expected staff to complete all sections of the nursing progress notes. CNO Staff C was queried if they expected staff to follow policies and procedures and they said "absolutely."

According to the facility's policy "Nursing Process," dated 6/2024, "The nurse, in collaboration with the treatment team, develops a plan of care by integrating each step of the nursing process. The plan of care is revised and updated as needed, and acts as a written guide for the documentation of the patient's care." The policy also revealed that "The nurse adds the revisions to the plan of care to the original document and records the rationale for the revisions in the medical record."

According to the facility's policy "Interdisciplinary Treatment Plan for Inpatient Services," dated 2/2025, "The Master Treatment Plan is reviewed and updated as frequently as necessary, but at a minimum, is reviewed every seven (7) days."

Based on interview and record review, the facility failed to document required nursing assessments for 6 (P-1, P-2, P-3, P-7, P-9, P-10) of 10 patients reviewed, resulting in the increased likelihood of negative outcomes for the patients. Findings include:

P-1 was admitted on 2/13/2025 for hallucinations, delusions, and agitation. On 2/16/2205 at 1220, P-1 fell while in the cafeteria.

On 2/17/2025 at 0600, P-1's post fall nursing progress note revealed that P-1 had a pain score of 5 and location included "L shoulder, ribs, elbow, hip, knee." There was no correlating nursing medical note documented in P-1's daily nurse progress note for the 1900-0700 shift.

On 2/18/2025, P-1's daily nurse progress note revealed that P-1 reported a pain score of 9 and then reassessed at 1000 with a score of 4 (0700-1900 shift). There was no correlating nursing medical note documented for the 1900-0700 shift.

On 2/19/2025, P-1's daily nurse progress note for the 1900-0700 shift revealed that P-1 reported chronic dull pain to left shoulder. However, no pain score was documented at that time.

On 2/20/2025 P-1's daily nursing progress note for the 0700 to 1900 shift revealed that P-1 had pain but there was no pain score documented. There was no medical note documented for the 1900 to 0700 shift.

On 2/21/2025, P-1's daily nursing progress note for the 0700 to 1900 shift revealed that P-1 had chronic pain to left shoulder, but no pain score was documented. There was no corresponding nurse medical note documented for the 1900 to 0700 shift.


P-7 was interviewed on 3/31/2025 at 1000 and revealed a concern that they told their nurse their ankle hurt on 3/29/2025 and P-7 reported there has been no update. On 3/29/2025 at 1725, P-7's daily nursing progress note revealed that "c/o of swelling to L ankle, pain 0/10."

On 3/30/2025 (no time recorded), P-7's daily nursing progress note for one shift revealed "Pt is stable." On 3/30/2025, there nurse medical note for the second shift was blank. On 3/31/2025, P-7's daily nursing progress note revealed that a pain assessment was not documented on the 0700-1900 shift.

On 3/31/2025 at 1235 Assistant Chief Nursing Officer (ACNO) Staff L confirmed that there was no order/consult generated by nursing to address P-7's ankle and confirmed the nurse should have documented the sore ankle as a medical condition in the nursing medical notes.


P-9 was admitted on 1/11/2025 with a history of psychosis. According to medical record review on 3/31/2025 at 1135, P-9 had missing pain assessments in the daily nursing progress notes on the following dates 2/11/2025 (0700-1900 shift), 1/12/2025 (0700-1900 shift), 1/13/2025 (0700-1900 shift), 1/20/2025 (0700-1900 shift), 1/21/2025 (0700-1900 shift), 1/23/2025 (0700-1900 shift), 1/25/2025 (0700-1900 shift), 1/26/2025 (0700-1900 shift), 1/27/2025 (0700-1900 and 1900-0700 shifts), 2/3/2025 (0700-1900 shift), 2/4/2025 (0700-1900 and 1900 - 0700 shifts), and 2/19/2025 (1900-0700 shift).

ACNO Staff L confirmed the findings during an interview on 3/31/2025 at 1215.


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P-2: This 45-year-old male was admitted to the facility on 2/21/25 with a diagnosis of major depressive disorder. During record review on 3/31/25, it was noted that the daily nurse progress notes failed to include pain assessments on 2/22/25, 2/24/25, 3/1/25, and 3/4/25. It was also noted that the nursing medical assessment on 2/22/25, 0700-1900 was blank.


P-3: This 22-year-old female was admitted to the facility on 2/25/25 with a diagnosis of paranoid schizophrenia. During record review on 3/31/25, it was noted that the daily nurse progress notes failed to include pain assessments on 2/27/25, 3/1/25, 3/3/25 (both shifts), and 3/6/25. It was also noted that the medical assessment on 3/6/25 (0700-1900) failed to include a nursing signature and the nursing medical assessment on 3/3/25 (1900-0700) was blank.

It was also noted that P-3 had fallen out of bed on 2/27/25 at 0320. The post fall nursing progress note indicated post fall follow up every shift for 24 hours following the fall. Shift one completed the assessment on 2/27/25 at 0930. The second shift assessment was blank. In addition, the physician ordered neuro checks every 2 hours for 24 hours. The medical record indicated neuro checks began on 2/27/25 at 0400. The last neuro check documented was at 1800 on 2/27/25. There was no evidence of a physician order to discontinue the neuro checks after 14 hours.

P-10: This 41-year-old female was admitted to the facility on 3/9/25 with a diagnosis of schizoaffective disorder. During record review on 3/31/25, it was noted that the daily nurse progress notes failed to include pain assessments on 3/11/25, 3/13/25, 3/14/25, 3/22/25, 3/23/25, and 3/24/25.

These findings were reviewed and acknowledged by the assistant chief nursing officer (Staff-L) during an interview on 3/31/25 at 1215.

The chief nursing officer (Staff C) stated all nursing staff are expected to follow policies and procedures during an interview on 4/1/25 at 1155.

Policy-16241747, Nursing Assessment (Last revised 7/23). States, "ALL sections of the nursing assessment MUST be completed."

Policy-16790103, Pain Management (Last revised 10/24). States, "In order to provide for a common language throughout the System, intensity will be documented using designated pain scale."